Reactions 1704, p300 - 2 Jun 2018
Focal immune-related pancreatitis: case report
A 76-year-old woman developed focal immune-related
pancreatitis following treatment with pembrolizumab.
The woman, who had urothelial carcinoma and local nodal
recurrence, started receiving treatment with IV
pembrolizumab 200 mg/3 weeks. Her concurrent treatment
included R0 nephroureterectomy, methotrexate, vinblastine,
adriamycin and cisplatin. Subsequently, she developed grade 2
diarrhoea and weight loss. Further CT examination revealed
mild dilation of the main pancreatic duct (MPD). Subsequent
MRI and cholangiopancreatography confirmed MPD dilation
secondary to a tapered stricture in the pancreatic head. On
diffusion-weighted image, a marked increase in signal intensity
of a region of the pancreatic head was observed, indicating
restricted diffusion. A subsequent endoscopic ultrasound
(EUS) revealed a 2cm hypoechoic solid lesion of the pancreatic
neck, stiff at elastography, with low vascularity after the
administration of contrast agent, causing stenosis of the MPD
with upstream dilation. Therefore, pancreatic adenocarcinoma
was suspected. However, fine-needle aspiration was found to
be negative for neoplasia, but revealed a dense granulocytic
inflammation. Subsequent laboratory investigation revealed
decreased level of faecal elastase 41 mcg/g (normal>200)
suggestive of exocrine pancreatic insufficiency.
Therefore, the woman was treated with pancreatic enzyme
replacement therapy. Subsequently, prompt diarrhoea
resolution and weight gain was observed. Two months later, a
follow-up EUS revealed disappearance of the lesions and only
ﬁnding of hypoechoic and inhomogeneous
parenchyma, diffuse hyperechoic foci and strands, with
pancreatic head atrophy. The MPD was found to be thin and
irregular. According to the Rosemont classification, these
findings were consistent with chronic pancreatitis.
Additionally, distal common bile duct and superior mesenteric
artery demonstrated thickening of walls (1 and 1.6mm,
respectively), as in cases of cholangitis and vasculitis. Two
months later, an MRI scan using diffusion-weighted imaging
revealed absence of any solid pancreatic lesion. She remained
asymptomatic, although faecal elastase levels remained low.
Her final diagnosis was focal immune-related pancreatitis
considered to be secondary to pembrolizumab treatment
[duration of treatment to reaction onset not stated].
Author comment: "We believe that clinicians using these
drugs [pembrolizumab] should be aware that immune-related
pancreatitis might present without amylase or lipase increase
or overt symptoms of acute pancreatitis but possibly as a
focal pancreatic lesion, and with diarrhoea and weight loss
due to [exocrine pancreatic insufficiency], which might be
appreciated by careful imaging procedures and measure of
faecal elastase levels."
Capurso G, et al. Focal immune-related pancreatitis occurring after treatment with
programmed cell death 1 inhibitors: a distinct form of autoimmune pancreatitis?
European Journal of Cancer 95: 123-126, May 2018. Available from: URL: http://
doi.org/10.1016/j.ejca.2018.02.006 - Italy
Reactions 2 Jun 2018 No. 17040114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved